Pancreatic carcinoma is the 4th most common cause of cancer related death worldwide and one of the most aggressive human tumors.
Despite improved quality of surgery,
the prognosis of patients with pancreatic cancer is still dismal.
At the moment of diagnosis,
in fact,
only 10% of neoplasms are confined to the gland,
while 40% are locally advanced and 50% show distant metastases.
Surgical resection still represents the best therapeutic approach but only 20–25% of patients can benefit from it with a median survival after surgery of 90% at 1 year and of 2– 4% at 5 years.
However,
the progressive increase in number of reference centres specialized in pancreatic surgery has helped to reduce the perioperative morbidity and mortality.
Thanks to these improvements,
many efforts have been done in order to extend the indications for curative surgery,
trying to obtain the maximum neoplastic removal by applying new surgical techniques such as retroperitoneal tissue cleaning and lymphadenectomy,
and vascular resection.
Moreover,
in order to obtain a pre-operative downstaging in patients with locally advanced disease,
chemo-radiotherapeutic protocols can be applied before surgery.
For these reasons,
while the presence of distant metastases,
peritoneal carcinosis or arterial infiltration is usually considered as absolute criteria of unresectability,
suspected porto-mesenteric axis infiltration,
lymph nodal metastases or peripancreatic invasion are now generally judged as relative criteria for unresectability [1].
Traditionally,
arterial invasion (celiac trunk,
hepatic artery,
superior mesenteric artery - SMA) has been deemed to be inoperable in patients with pancreatic head cancer because of the high morbidity of arterial reconstruction and the concomitant presence of extensive celiac or mesenteric neural invasion.
Moreover,
a positive surgical margin,
whether gross or microscopic,
predicts survival similar to that of patients who have locally advanced disease and who are considered as surgically unresectable.
However,
nowadays the indication of treatment in case of arterial infiltration are debated; according to some authors,
early arterial invasion is considered resectable in carefully selected cases,
like isolated infiltration of celiac trunk or common hepatic artery [2],
particularly in cases responding to neoadjuvant chemoradiotherapy.
Instead,
the infiltration of mesenteric-portal veins may be present also in absence of an extended retroperitoneal fat tissue infiltration,
so that,
while only ten years ago a cancer showing sign of infiltration of the portal venous axis was considered as locally advanced and unresectable,
this is no longer true.
In fact,
many studies from reference centres specialized in pancreatic surgery indicate the opportunity of a venous vascular resection as the standard treatment of pancreatic cancer involving the mesenteric-portal veins,
demonstrating that survival of patients submitted to pancreatectomy with vascular venous resection is not different or sometimes better than that of patients subjected to standard pancreatectomy,
in particular when a curative surgery has been obtained (R0) or when microscopic neoplastic residual is present (R1) [2].
This concept has been confirmed in the most recent expert consensus statement published in 2009 by the American Society of Surgeons [3].
Regarding peripancreatic fat tissue infiltration,
literature data indicate that about 40% of pancreatic resections are not radical because of the presence of a microscopic residual on one of the surgical margins.
In particular,
in cases of pancreatic adenocarcinomas of the head/ uncinate process,
the prognosis after surgery is strongly influenced by the persistence of tumoral involvement at the retroperitoneal resection margin (also called SMA margin,
according to the 2009 expert consensus statement),
mainly by virtue of the difficulty of obtaining a radical debulking at that site.
Even if it is still only at laparotomy that resectability can be definitely determined,
the quality of surgical resection has improved over the last decade thanks to a better preoperative imaging staging.
For these reasons,
an adequate pre-operative evaluation is mandatory in order to select resectable patients,
who may really benefit from surgery in terms of survival.
Aim of our study was to evaluate the predictive value of multidetector CT in assessing resectability in patients affected by locally advanced ductal adenocarcinoma of the pancreas submitted to surgery with vascular resection.
As second goal,
the local staging parameters were compared with survival in order to identify possible prognostic factors of survival at preoperative CT.